Provider Demographics
NPI:1316347180
Name:MORALES ROSA, JACKELINE (LCDA)
Entity type:Individual
Prefix:
First Name:JACKELINE
Middle Name:
Last Name:MORALES ROSA
Suffix:
Gender:F
Credentials:LCDA
Other - Prefix:
Other - First Name:JACKELINE
Other - Middle Name:
Other - Last Name:MORALES ROSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCDA
Mailing Address - Street 1:HC 02 BOX 9778
Mailing Address - Street 2:
Mailing Address - City:AIBONITO
Mailing Address - State:PR
Mailing Address - Zip Code:00705
Mailing Address - Country:US
Mailing Address - Phone:787-617-0346
Mailing Address - Fax:
Practice Address - Street 1:CALLE JOSE C VAZQUEZ # 62
Practice Address - Street 2:
Practice Address - City:AIBONITO
Practice Address - State:PR
Practice Address - Zip Code:00705
Practice Address - Country:US
Practice Address - Phone:787-617-0346
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR1886133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist